Organizational Infrastructure

Policy Framework – Governance and Accountability

A health information technology infrastructure is essential to transform today's largely paper-based system to an electronic, interconnected system that will help address many of the challenges facing New York's health care system, including: preventable medical errors, disparities in the quality of care New Yorkers receive, high costs, administrative inefficiencies and the lack of coordination among physicians, hospitals and patients. Currently, New York's health IT strategy and investment exceeds $390 million. The financial support for the Statewide Health Information Network for New York (SHIN-NY) and the other components of the technical infrastructure constitute only one aspect of the overall framework. More importantly, the organizational infrastructure is comprised of a policy and governance framework, collaborative processes and accountability mechanisms on which the strategy is being implemented, including:

The New York eHealth Collaborative (NYeC, pronounced "nice") is a State designated public-private partnership and statewide policy body playing an integral role in the implementation of New York State's health IT strategy through a consensus-based approach. Key responsibilities include (1) convening, educating and engaging key constituencies, including health care and health IT leaders across the state, Regional Health Information Organizations, Community Health Information Technology Adoption Collaboratives ("CHITAs"), and other health IT initiatives; (2) developing Statewide Policy Guidance through a transparent governance process and (3) evaluating and establishing accountability measures for New York's health IT strategy.

At the present time, New York State has elected to develop health information policies, standards and technical protocols governing the health IT infrastructure – collectively referred to as Statewide Policy Guidance. NYeC, in partnership with the DOH, is leading the development of statewide policy guidance through an open, transparent, and consensus driven process to which all contribute to ensure health IT advances in the public's interest. This process is referred to as the Statewide Collaboration Process (SCP). The SCP is largely driven by the efforts of its four collaborative workgroups, which recommend policies and procedures, standards, technical approaches and services to the NYeC Policy and Operations Council, the NYeC Board and the NYS DOH. The four workgroups are: (1) Clinical Priorities; (2) Privacy and Security; (3) Technical Protocols and Services; (4) EHR Collaborative. As part of its commitment to the public-private infrastructure evolving to support statewide interoperability, the State of New York has committed $5 million to NYeC over the next two years to manage the statewide collaborative process.

The Statewide Collaboration Process

Regional Health Information Organizations (RHIOs)

Underlying the Statewide Health Information Network for New York and central to its successful implementation are RHIOs. New York's RHIOs, working under the NYeC umbrella and with their stakeholders and constituents must create an environment that assures effective health information exchange both organizationally and technically through a sound governance structure. RHIOs are required to participate in the statewide collaboration process managed by NYeC setting statewide policy guidance and then must implement and ensure adherence to such guidance. Serving as trusted brokers, RHIOs are multi-stakeholder collaborations that enable the secure and interoperable exchange of health information with a mission of governing its use in the public's interest and for the public good by supporting improvements in health care quality, affordability and outcomes. Currently, there are nine state designated RHIOs, which are part of the statewide governance structure and provisioning health information exchange services via the SHIN-NY over the next two years. By virtue of fulfilling their obligations, RHIOs will be conferred benefits in terms of eligibility for grants, contracts for services, and access to various data sources, both public and private.

CHITAs are community-based collaborations of clinicians and providers in a defined care coordination zone with a mission to advance the adoption and effective use of interoperable electronic health records (EHRs). The State of New York is currently funding nine CHITAs to ensure that effective adoption and use of interoperable EHRs result in patient care improvements. CHITAs will facilitate the provision of adoption and support services, such as workflow re-design and process and quality interventions and improvement. In contrast to RHIOs, which must be independent not-for-profit entities, CHITAs are informal collaborations of provider participants in a care coordination zone for the purpose of sharing software, technical services, and clinical services and ensuring groups of clinicians realize up-front and consistent value from interoperable EHRs.

HITEC is a multi-institutional, academic collaborative of New York State institutions including Cornell University, Columbia University, the University of Rochester, the State University of New York at Buffalo, and the State University of New York at Albany, and serves in a research and evaluative role with respect to health IT initiatives in New York State. HITEC was formed to evaluate and develop evaluation instruments for Health Information Evaluation (HIE) initiatives across the State, while integrating a variety of stakeholders, including providers, payers, employers, foundations, the federal government, RHIOs and vendors. HITEC has been charged with providing evaluation services for HEAL NY Phase 5 grantees in a consistent and objective manner across all funded projects. The State of New York has committed $5 million to HITEC over the next two years.

A high-level representation of the key building blocks and relationships is illustrated below:

Governance and Organizational Components: Policy Development and Implementation Framework

Diagram Key

RHIO: A governance entity that oversees HIE in its region

CHITA: A local collaboration supporting EHR adoption with an emphasis on primary care and Medicaid providers

Roles and Responsibilities

It is important to note that New York's framework for a comprehensive, interoperable health information infrastructure is predicated on distinguishing between the responsibility for setting policy, which is the province of the state (policy with a "big P") and is assisted by a state designated public-private partnership, the New York eHealth Collaborative (NYeC) through a transparent governance process (policies with a "little p"; the responsibility for implementing health information policies, which is the province of RHIOs and CHITAs; and the responsibility for compliance with the Common Health Information Exchange Protocols (CHIxP) and standards, which is the responsibility of the health information service provider companies providing health information exchange software and technical services that are contracted by the RHIOs, CHITAs or NYeC.

Through the statewide collaboration process managed by NYeC, a policy framework to develop and maintain information policies is being formulated in the public's interest through a transparent governance process and the technical development and implementation of a dynamic, bi-directional health information infrastructure is underway. The policy framework and governance as well as the technical infrastructure implementation are inextricably linked and essential to advancing interoperable health information exchange supporting care coordination, quality improvement interventions, public health reporting and biosurveillance activities.

Moreover, this distinction between policy, governance and the provision of technology services in advancing interoperability via the SHIN-NY is critical to understanding exactly what accountability mechanisms should be in place. Given the central governance role played by RHIOs in New York and their receipt of substantial public funding, it is essential they be held publicly accountable. Moreover, accountability is important not just from the state's perspective. For RHIOs governing the SHIN-NY to be successful, all stakeholders – state and local governments, providers, payers, and consumers – must have confidence that RHIOs serve the public interest and perform the duties expected of them in a transparent manner that earns public trust. Accordingly, based on New York State's health IT strategy and leadership from the Department of Health, the New York eHealth Collaborative (NYeC) initiated a research project to examine alternative pathways for ensuring the public accountability of RHIOs enabling the SHIN-NY, including how an accreditation process could establish a mechanism to define measures for and assess RHIO performance.

A governance accreditation program would not focus on data standards or technical products and services required to achieve health information exchange, which ideally, would be the domain of certification programs being developed by the Certification Commission for Health Information Technology (CCHIT). Rather, accreditation would focus on the structure, process and outcomes of governance entities such as RHIOs as it relates to their principal mission of participating in the information policy setting process, implementing policies and ensuring adherence to such policies to protecting the privacy and security of health information in the public's interest and ensuring that health information is used to improve health care outcomes and promote efficiency.

New York's efforts to assess accreditation as a viable component of accountability dovetails with work being conducted in other states and by the federal government. The New York eHealth Collaborative (NYeC) released a white paper that examines the potential role for accreditation of the governance functions necessary to advance interoperable health information exchange as part of New York's health information technology (health IT) strategy. For many states, the development of a national accreditation process holds the promise for a multi-state accountability framework that fosters consistency and facilitates health information exchange across jurisdictions. With respect to alignment with federal efforts, New York's evolving accountability infrastructure will both inform and be informed by the plans to define the nature, phasing, and timing of the roles and responsibilities of the American Health Information Community successor organization charged with advancing nationwide interoperability.